Complaint Investigation Report

Allegation: “Resident developed stage 3 pressure injury while in care”, it is being alleged that R1 developed a stage 3 pressure injury while in care. Records reviewed revealed the following: Physicians Report dated 10/15/2024 indicates that R1 has a history of pressure injuries. R1’s Admission Agreement is dated 10/18/2024. R1 began Home Health on 11/10/2024 and the report indicates that R1 had a risk of pressure injuries but had no pressure injuries at the time of assessment and the goal for R1 was not to develop any pressure injury. From 11/10/2024 to 12/24/2024, R1 received Home Health services; Home Health staff instructed facility caregivers to check skin for any signs of pressure injuries and change position of R1 every two hours. R1 was hospitalized on 12/24/2024 and was discharged on 12/28/2024. There are no records of Home Health services provided to R1 from 12/25/2024 to 01/28/2025. On 12/28/2024, Progress Notes indicates that the Primary Physician diagnosed R1 with a stage 2 sacral decubitus ulcer measuring 0.5cmx0.5cmx0.1cm, there is no documentation indicating that R1’s Primary Physician performed wound care from 12/28/2024 to 01/28/2025. The facility did not maintain a record of R1 being repositioned every two hours or of care provided with all aspects R1’s pressure injury. On 01/28/2025, hospital and medical records indicate that during admission R1 was diagnosed with stage 3 and stage 4 pressure injuries in the buttocks area. Interviews conducted revealed the following: On 02/27/2025, R1 confirmed that staff would not reposition them every two hours. On 04/29/2025, 2 out of 6 staff indicated that staff would not reposition residents if they were in wheelchairs, unless residents requested it; 5 out of 6 staff confirmed that on December 2024 they saw an injury (e.g., the size of a bean, Q-Tip, and quarter) right above R1’s behind (e.g., buttock, coccyx). Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An immediate civil penalty of $500.00 is being assessed please see LIC421IM.